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Background: Reduction of variability through process reengineering can improve surgical results for patients with type A acute aortic syndrome. We compare short-term results before and after implementation of an Aorta Code for patients with type A acute aortic syndrome who underwent surgery., Methods: The Aorta Code was implemented in a 5-hospital healthcare network in 2019. This critical pathway was based on a simple diagnostic algorithm, ongoing training, immediate patient transfer, and treatment by an expert multidisciplinary team. We retrospectively compared all patients operated on in our center before (2005-2018) and after (January 2019 to February 2023) its implementation., Results: One hundred two and 70 patients underwent surgery in the precode and code periods, respectively. In the code period the number of patients operated on per year increased (from 7.3 to 16.8), and the median elapsed time until diagnosis (6.5 hours vs 4.2 hours), transfer (4 hours vs 2.2 hours), and operating room (2.7 hours vs 1.8 hours) were significantly shorter (P < .05). Aortic root repair and total arch replacement were more frequent (66.7% vs 82.9% [P = .003] and 20.6% vs 40% [P = .001]). Cardiopulmonary bypass and ischemia times were also shorter (179.7 minutes vs 148.2 minutes [P = .001] and 105 minutes vs 91.2 minutes [P = .022]). Incidence of prolonged mechanical ventilation (53.9% vs 34.3%, P = .011), major stroke (17.7% vs 7.1%, P = .047), and 30-day mortality (27.5% vs 7.1%, P = .001) decreased significantly., Conclusions: An Aorta Code can be successfully implemented by using a standardized protocol within a hospital network. The number of cases increased; time to diagnosis, transfer, and operating room were reduced; and 30- day mortality significantly decreased., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Thrombocytopenia is a common, yet poorly understood, complication after transcatheter aortic valve replacement (TAVR). Balloon-expandable transcatheter heart valve has been associated with higher incidence of thrombocytopenia, compared with self-expandable valves. The aim of this study was to analyze the incidence, clinical impact and predictors of acquired thrombocytopenia in patients undergoing TAVR., Methods: We performed an observational study from consecutive patients with severe aortic stenosis undergoing TAVR (n = 679) in a single center. Association and best cut-off point of platelet decrease with early mortality was analyzed. Patients were classified according to postprocedural percentage decrease in platelet count (PDPC), comparing clinical outcomes and analyzing predictors of platelet decrease., Results: The median PDPC was 37.1 [IQR: 27.4-46.9]. PDPC was associated with early mortality (OR: 2.1, 95%IC: 1.7-2.5 for each 10% decrease, AUC:0.81, 95%CI:0.72-0.89) with an optimal cut-off point of 46%. PDPC≥46% and late nadir (≥4 days) were both independent predictors of early mortality (OR: 6.0 [IQR: 2.4-14.9] and OR: 5.1 [IQR: 2.2-11.6], respectively). The combination of both factors (PDPC≥46% and nadir ≥4 day) was associated with higher 2-year mortality (55.7%) compared to an early significant nadir (PDPC≥46% and nadir <4 day, 28.9%) and non-significant nadir (PDPC<46%, 21.0%), p < 0.001. Independent predictors of PDPC≥46% were baseline platelet count, Portico™, Abbott valve, intraprocedural major vascular complication and residual aortic regurgitation ≥grade 2., Conclusion: The platelet count decreased almost 40% after TAVR. Late nadir and PDPC≥46% predicted short-term clinical outcomes. Concomitant late and significant platelet decrease was associated with mid-term mortality., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Infective endocarditis (IE) in patients with a valve-tube ascending aortic graft (AAG) is a rare entity with a challenging diagnosis and treatment. This study describes the clinical features, diagnosis and outcome of these patients., Methods: Between 1996 and 2019, 1654 episodes of IE were recruited in 3 centres, of which 37 patients (2.2%) had prosthetic aortic valve and AAG-IE (21 composite valve graft, 16 supracoronary graft) and conformed our study group., Results: Patients with aortic grafts were predominantly male (91.9%) and the mean age was 67.7 years. Staphylococci were the most frequently isolated microorganisms (32%). Viridans group streptococci were only isolated in patients with composite valve graft. TEE was positive in 89.2%. PET/CT was positive in all 15 patients in whom it was performed. Surgical treatment was performed in 62.2% of patients. In-hospital mortality was 16.2%. Heart failure and the type of infected graft (supracoronary aortic graft) were associated with mortality. Mortality among operated patients was 21.7%. Interestingly, 14 patients received antibiotic therapy alone, and only one died. Mortality was lower among patients with a composite valve graft compared to those with a supracoronary graft (4.8% vs 31.3%; p = 0.03)., Conclusions: In patients with AAG and prosthetic aortic valve IE, mortality is not higher than in other patients with prosthetic IE. Multimodality imaging plays an important role in the diagnosis and management of these patients. Heart failure and the type of surgery were risk factors associated with in-hospital mortality. Although surgical treatment is usually recommended, a conservative management might be a valid alternative treatment in selected patients., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Two high-risk patients were successfully treated with concomitant implantation of a transapical off-pump beating heart semirigid D-shape annuloplasty device combined in 1 case with a transfemoral edge-to-edge device and in another with transapical chordal implantation. The significant anteroposterior diameter reduction offered by the annuloplasty implantation maximized the leaflet coaptation obtained by the prolapse correction performed with the leaflet devices. Combining the transcatheter annuloplasty device and leaflet/chordal repair technologies represents progress toward definitive transcatheter treatment of degenerative mitral valve disease., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Transcatheter aortic valve implantation (TAVI) techniques have been presenting good procedural success and favorable clinical outcomes. However, optimal management of aortic valve disease in elderly patients depends on quality of life (QoL) improvement. In this study we aimed to evaluate changes in QoL in patients referred for TAVI., Methods and Results: Prospective analysis of 74 consecutive patients (34 male), aged 81.6 ± 8 years with symptomatic severe aortic valve stenosis (AS) ineligible for conventional aortic valve replacement, referred to TAVI in one tertiary center. For the assessment of QoL, the Minnesota Living with Heart Failure Questionnaire (MLHFQ) was used before the procedure and at 6.5 months. The mortality was 9.5% at 30 days and 20.2% at 6.5 months follow-up. Fifty three (71.6%) patients completed MLHFQ at baseline and at follow-up. All patients showed good hemodynamic results and no signs of prosthesis dysfunction were observed on transthoracic echocardiography. The New York Heart Association (NYHA) class (2.9 ± 0.4 to 1.4 ± 0.7; p<0.001), and the MLHFQ scores [overall (37.0 ± 14.7 vs. 14.4 ± 10.1; p<0.001), physical dimension (23.2 ± 9.5 vs. 8.6 ± 5.9; p<0.001) and emotional dimension (5.4 ± 4.2 vs. 2.6 ± 3.0; p<0.001)] were significantly improved 6.5 months after TAVI. Patients with peripheral vascular disease (PVD) had an inferior improvement in QoL caused by a lower enhancement in physical dimension MLHFQ score (mean difference: -17.0 ± 10.2 vs. -10.1 ± 11.5; p=0.036)., Conclusion: TAVI significantly improves symptoms and QoL in patients with severe AS and high surgical risk. Patients with PVD might be expected to have a less impressive improvement in QoL after TAVI., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: The aim of this study was to analyze surgery and survival data in the midterm after aortic root and (or) ascending aorta reoperations and compare these results with those obtained after first time surgery., Methods: Over a 6-year period, 365 patients underwent an aortic root and (or) ascending aorta surgery procedure at our center. Mean patient age was 63.1 + or - 25.5 years; 27.1% were women. Fifty-eight patients had had prior ascending aorta and (or) aortic valve surgery (group I) and the remaining 307 patients were assigned to an initial surgery group (II). The reoperative procedures were Bentall in 45 (77.6%), ascending aorta and valve replacement in 8 (13.8%), and ascending aorta replacement in 5 (8.6%)., Results: The reoperation group showed a worse preoperative risk profile indicated by a higher logistic European system for cardiac operative risk evaluation: group I (26.9) versus group II (9.9) (p < 0.0001). Hospital mortality was 7 of 58 (12.1%) in group I and 21 of 207 (6.8%) in group II (p = 0.18; relative risk 1.9 [0.8 to 4.6]). After adjusting for the different variables, reoperation could not be identified as an independent predictor of postoperative morbidity. Survival rates (including in-hospital mortality) were lower in group I at one year (77.9 + or - 1.11% vs 91.9 + or - 0.3%) and at 3 years (75.3 + or - 0.11% vs 88.9 + or - 0.03% [log-rank p = 0.005]). In the multivariate analysis, reoperation (p = 0.01; hazard ratio 2.6 [1.2 to 5.3]) was a determining factor for survival once corrected for variables predicting mortality during follow-up., Conclusions: Reoperations on the ascending aorta and aortic root showed acceptable morbidity and mortality. Their midterm survival was lower than for patients not requiring a repeat operation., (Copyright 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Development of an intracardiac fistula is a rare complication after mitral valve replacement. In the literature we have found six cases of left ventricular-coronary sinus fistula and another one of left ventricular-coronary sinus and right atrial fistula. We report the history and course of a patient in whom a left ventricular-coronary sinus and right ventricular fistula developed late after mitral valve replacement. The current study examines this type of intracardiac shunt, and presents our report on a left ventricular-coronary sinus and right ventricular fistula complication.